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Pay Hundreds of Thousands for the Heart Attack, or Pennies to Prevent It?

I began to glimpse inside the true chaos that governs the US health care system during my first year of residency – the real start of “hands on training” after my mostly theoretical medical school.

I entered a training program for family medicine in large part because I recognized the value of primary and preventive care.  As someone who had studied infectious diseases, it just made sense that preventing disease is always better than trying to scramble to treat it when it pops up.

Aside from the medicine, a steep part of my learning curve in residency was figuring out how to negotiate private insurance, Medicare, and Medicaid. No one ever taught me how any of these worked, or how much their rules would affect my practice. 

My first week in clinic as a “real MD”, I found out Medicare didn’t cover prevention. 

When I tried to screen a newly covered 65 year old patient for high cholesterol with a blood test, I was told I couldn’t use a “screening code” to order it.  It was explained to me that if I already knew the man had high cholesterol or he’d had a heart attack for example, I could code those things as problems and get the blood test I wanted.

But just to check - to try and head off a problem before it occurred? – no way.

“It’s just the way Medicare works,” my attending (teaching) physician explained. “Medicare will pay hundreds of thousands of dollars for the heart attack, but won’t pay a penny to prevent it.”

It turned out that the problem was not just Medicare, but that our entire health care system has its ground-rules written around episodic/problem-based care and payment, instead of being built around people, prevention, and what works to maintain the best health for our communities.

A strong, healthy, productive nation is what we want.  Healthy lifestyles and high value health care that prevents disease and treats it most effectively when it hits should be our goal.  

Research shows comprehensive prevention interventions make a difference – controlling costs and ensuring American workers are healthier. 

A decade away from that residency experience, I’m thrilled to see our nation finally beginning to take some steps to recognize the promise of prevention, primary care, and better health.  We still have a long, long way to go, but a few helpful provisions of the new health care law – the Affordable Care Act (ACA)- went into effect as of January 1, 2011.

Reversing the absurd Catch-22 my patients and I struggled with, Medicare enrollees will be now able to get many preventive health services - such as vaccinations and cancer screenings – for free. Specifically, the law eliminates any cost-sharing - copayments/deductibles - for Medicare-covered preventive services (that are rated A or B by the U.S. Preventive Services Task Force).

Medicare beneficiaries can also get a free annual "wellness exam" from their doctors who will set up a "personalized prevention plan" for them. The plan includes a review of the patient’s medical history and a screening schedule for the next 10 years.

Listening to the pleas of doctors, nurses, patients, and faith-based supporters such as the Catholic Hospitals Association, a recent ruling pushed aside the revolting partisan attacks that swirled around “end-of-life” discussions, and clarified that these important consultations with your personal physician can be included in the “wellness visit” if you want. 

The 20% co-pay on the "Welcome to Medicare" physical exam has also been eliminated.

Finally, Medicare is increasing payments for primary care by 10 percent through the end of 2015. Doctors, nurses, nurse practitioners, physician assistants, and others who work in primary care are significantly underpaid relative to their colleagues in other specialties, and this effort will certainly help - but will not ultimately solve the problem.  Health practitioners will qualify for the bonus only if 60 percent or more of the services they provide are for primary care. (This qualifier may leave out some rural physicians who provide a broad scope of services and continuity of care for their patients. General surgeons in underserved areas are an exception to this qualifier. We should work to get all primary care physicians in underserved areas excepted as well.  But that’s part of the “work left to be done” category – a topic for another post…stay tuned.)

Other important wellness provisions of the new health care law (the ACA) that start this year:

  • The federal government will issue $200 million in grants for companies with fewer than 100 workers that start wellness programs focused on nutrition, smoking cessation, physical fitness and stress management.
  • Restaurants with 20 or more locations, and owners of 20 or more vending machines, will have to display calorie information on menus/menu boards/drive-thru signs. Restaurants also have to provide diners with a brochure that includes detailed nutritional information, such as the fat and carbohydrate content of their dishes.
  • So, these efforts should help ensure American seniors stay healthy longer, help American consumers stay informed and healthy as well, begin to re-focus our efforts on disease prevention, saving lives and saving money…

These are ideals all Republicans, Democrats, and Independents should be able to rally around…right?

We shouldn’t let someone take away the progress we just won with a repeal of the Affordable Care Act, should we?? – that would lead us right back where we came from.  

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